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The Battle of Yellow Jack: a comparative look at preventive medicine during the American Civil War.

The US Army is an organization built upon what is often described as "tribal lore." Tribal lore is a concept whereby the elders of the tribe imbue the lessons learned from past trials, tribulations, and experiences to the younger members of the tribe. In tribal societies, this feat is accomplished through storytelling, observation and emulation. In short, tribal lore at its most basic foundation is the application of best practices and lessons learned. The modern US Army employs the same techniques, albeit in a codified and structured, methodological manner, through the after action review process and ultimately the creation of doctrine and Army regulations.

The current Army Regulation 40-5 (1) specifies:
   The overall objectives of field preventive medicine are
   to provide commanders with healthy and fit deployable
   forces;  to sustain the health and fitness in any military
   operation;  and to prevent casualties from DNBl [disease
   and nonbattle injuries] and stress reactions. (1) (p4)


But what did the Army do before the implementation of Army-wide policies and regulations concerning preventive medicine? History is replete with examples of what the Army did or, more often than not, failed to do. One need only look a mere 150 years in the past to find prime examples.

During the American Civil War, the most costly of all American conflicts, it is estimated that over twice as many Union Soldiers died of diseases (250,152) than were killed in action (110,070). (2) Clearly, preventive medicine, or the lack thereof, played a key role in the composition and disposition of the Union Forces during the American Civil War. An example of that fact is the story of how two Union commanders, during two different years in two separate theaters of war, approached the same task of executing preventive medicine programs to thwart yellow fever, resulting in two completely different outcomes.

MG Benjamin Butler, a politically appointed general with no formal military training, arrived to take control of the fallen Confederate city of New Orleans, Louisiana, on May 1, 1862. Occupying and controlling the rebellious, former Confederate shipping hub would be a daunting task for Butler and his Union forces requiring the full range of public administration tasks, not the least of which was dealing with annual scourge of yellow fever. (3) (pp36,37) Yellow fever was colloquially known as "Yellow Jack," a name derived from the age-old nautical tradition requiring arriving ships with known health problems to fly the all-yellow international maritime signal flag for the letter "Q" to signify that a contagious disease was present on the ship. That ship and its crew were then under quarantine until cleared by the port authority medical staff. (4)

Yellow fever was the most mysterious and terrifying of all southern diseases. It is typified by fever, jaundice, headaches, bleeding from the nose and mouth and in its final stages, vomiting of a dark, coffee ground-like material which was actually half digested blood. Fatality rates for those afflicted with this malady ranged up to 50%. Those who did survive a yellow fever outbreak were rewarded with life time immunity to the disease. The fever appeared annually throughout the coastal regions of the south during the late summer months and had the potential kill hundreds, or even thousands, especially the unacclimatized. For this reason, yellow fever was often known locally as "the strangers' disease." The fear of this disease had major psychological impacts upon the northern Soldiers of Butler's command who marched into the streets of New Orleans in 1862. (3) (pp3,15) It appears that many in Butler's command were more afraid of yellow fever than they were of any Confederate Soldier.

The cause of yellow fever was still unknown in 1862. Not until the groundbreaking work of Army physician MAJ Walter Reed in the early 20th century would the medical community understand that yellow fever was actually spread through the bites of the Aedes aegypti mosquito. (5) The conventional medical wisdom of the mid 19th century medical community held that yellow fever was spread through unsanitary conditions and the unhealthy, bad air created by those conditions. In fact, this theory is partially true. Unsanitary conditions created havens for the mosquitoes, and thereby perpetuated the spread of the deadly disease. Based upon the perceived impact yellow fever would have on his command and the need to do something about it, Butler devised a plan to establish a proactive campaign to battle the conditions of Yellow Jack. He believed that if he eradicated the conditions required for Yellow Jack, meaning the bad air, he could then control the disease. Butler's plan was simple and straightforward. First, he consulted not only with his assigned Union Army medical staff, but more importantly with the local doctors. By virtue of location, the local physicians had experience in dealing with the annual yellow fever outbreaks, although many of were initially reluctant to assist. (3) (p38)

Butler implemented a 2-pronged, simultaneous attack on yellow fever in New Orleans. His strategy included a strict quarantine of any vessels arriving in New Orleans and a comprehensive field sanitation program to rid the city of bad, unhealthy air. A ship quarantine station was established some 70 miles south of the city, manned by Union troops and local physicians with orders to detain and quarantine for 40 days any vessel thought to be infected with yellow fever. In a rather Draconian step, Butler threatened the local physicians with execution in the event that any infected ship was allowed though the blockade. Simultaneously, Butler employed a literal army of local workers and Soldiers to work around the clock executing a wide range of field sanitation efforts to remove standing, stagnant water, trash, and human and animal waste products throughout the city. The northern press praised Butler's initiatives, with Harper's Weekly stating that "he will probably demonstrate before the year is out that yellow fever, which has been the scourge of New Orleans, has been merely the fruit of native dirt and that a little Northern cleanliness is an effectual guarantee against it." (3) (p38) In 1863, Harper's Weekly published a cartoon of a scrub brush and soap wielding Butler standing in front of an approving Abraham Lincoln. Butler's efforts ultimately had the results that he sought; only 2 cases of yellow fever death resulted in New Orleans in all of 1862 and, more importantly, the paralyzing fear of yellow fever which once strangled the northern troops as they entered New Orleans was mitigated under Butler's Union control. (3) (p38) Butler's efforts had controlled the disease as well as the fear that it created. Butler's actions had a long-term impact of the Crescent City, with only 11 yellow fever deaths occurring in New Orleans between 1862 and 1865. However, after civil authority was returned to the civilians of New Orleans in 1866, 185 people died of yellow fever. That number soared to 3,107 deaths in 1867. Over 4,000 died of yellow fever in New Orleans during the sweeping epidemic of 1878, including noted Confederate General John Bell Hood, his wife, and one of his 11 children. (6)

Butler's fundamental but effective preventive medicine program had proved successful in New Orleans. However, the scene 2 years later and 965 miles away in New Bern, North Carolina, was a different story altogether. The eastern North Carolina community of New Bern is a low lying town, surrounded by swamps and marshy land. The summer of 1864 had been characteristically wet and humid, bringing with it swarms of the ubiquitous southern mosquitoes. Since its occupation by Union forces in 1862, New Bern had become a military hub, crowded with troops and the trappings of an army of occupation. MG Butler himself, as he approached the town in 1864, described New Bern as having "an awful stench" and further observed that the sanitation ditches in the Union camps were never filled in or covered, and the camps were moved when the smell of human excrement made the location of the camp unbearable. (7) Unlike Butler's command in New Orleans 2 years earlier, BG Innis Palmer's command had taken virtually no preventive medicine steps that did anything to thwart a yellow fever outbreak. In fact, the lack of Union camp sanitation plans and poor Union camp discipline, combined with a long, hot, wet summer, obviously had the opposite effect, actually setting the stage for a yellow fever epidemic.

When yellow fever did strike New Bern in 1864, it began very quietly and without much fanfare. History reports that SGT Mason Rogers of the Fifteenth Connecticut was the first yellow fever casualty of 1864, succumbing to the ravages of the disease on September 9, 1864. Union surgeon Dr Hubert V. C. Holcombe, who had spent time in Vera Cruz, Mexico, before the war and was well acquainted with the symptoms of yellow fever, reported the death and his suspicion about a yellow fever outbreak up the Union chain of command. None of the other Union physicians had ever personally observed a yellow fever outbreak. That was about to change. Medical Director for the Department of North Carolina, Dr D. W. Hand, initially denied the existence of yellow fever within the command and is even reported to have scolded Holcombe for trying to create a stir. When presented with overwhelming medical evidence of the disease, Dr Hand finally relented and acknowledged the existence of yellow fever and reported the findings to his superior, BG Innis Palmer. Dr Hand received treatment in kind from BG Palmer and was subjected to scorn and ridicule, while being accused of ignorance of southern diseases. (3) (p106)

Finally, in the face of increasing sickness within the command, both Palmer and Hand were forced to accept that yellow fever had indeed struck New Bern. However, the District of North Carolina chain of command kept the outbreak from the press for fear of creating a panic amongst both the Union troops and the North Carolina population. Palmer and Hand's efforts proved fruitless, since history records that Union sailors as far south as Beaufort, South Carolina, knew of the outbreak of symptoms of yellow fever even before Sergeant Rogers' death. (3) (pl06) Because of cover-up and initial inaction, the District of North Carolina and the Union garrison at New Bern were forced into a reactive rather than proactive scenario with regard to dealing with the yellow fever outbreak.

When finally spurred to action, Union forces in New Bern executed with a vengeance in an attempt to thwart the spread of yellow fever. Union officials enacted a strict quarantine system and burned pine branches and barrels of tar in the streets to "purify the air." Buildings thought to be infected with yellow fever were burned to the ground, and as many healthy Soldiers as possible were given furlough or transferred to "healthy" locations inland to prevent their infection, although some units remained in place to maintain law and order, implement sanitation measures and care for the sick. (3) (p107) By October 1864, the plague had hit its peak and Union forces were so decimated by the disease that Union officials ordered the newly formed and untrained First North Carolina Colored Heavy Artillery to move rapidly to New Bern to assist with sanitation operations. It was believed that that the locally raised black troops would be immune to yellow fever and thus fare better in New Bern. The First North Carolina reportedly spread 200 loads of lime around the dwellings of New Bern making the city appear to be blanketed in snow. Likewise, the First North Carolina cut down and burned over 500 cords of woods as well as 200 barrels of turpentine. (7) (p24) However, contrary to the conventional medical thought of the day, the locally raised Soldiers of the First North Carolina were not completely immune to yellow fever; 58 Soldiers fell sick with the disease, and 15 of them died. The first frost of November 1864 brought an end to the epidemic. However, the total cost to Union forces was 763 Soldiers sickened by yellow fever and 303 died. Additionally, 16 medical personnel were sickened by the disease, 8 of whom died. (3) (p107) In 1864, yellow fever caused more casualties to the Department of North Carolina than the Confederate Army. In addition, historians estimate that the civilian death toll from the outbreak in and around New Bern numbered well over 1,000. (7) (p26)

The net result of the yellow fever outbreak in New Bern was that the Union Army's Department of the Southeast finally published strict standing orders, based largely upon the horrors of the New Bern epidemic. These orders required district level commanders to maintain sterling camp sanitation standards (including the very liberal use of lime), the quarantine of all Confederate deserters and refugees, and to keep the results of New Bern quiet to avoid a panic amongst the Soldiers, the civilian population and the press. (3) (p107)

Based upon the historical facts concerning these separate preventive medicine operations, what lessons can be learned that apply for commanders in the 21st century? How did actions, or inactions, by each command ultimately impact the operational capability of the commands, and what were the long-term implications?

Dr Lion Poles of the Kaplan Medical Center (Rehovot, Israel) provides an excellent, simple, 12-step model for biological event consequent management consisting of the following logical steps (8):

1. Preparation

2. Detection

3. Diagnosis/event confirmation

4. Containment

5. Management of the population at risk

6. Triage

7. Management of the sick

8. Handling of the deceased

9. Dealing with high risk zones

10. Investigative actions

11. Political aspects

12. Determining the end of the event

When overlaid upon the Poles 21st century biological contingency model described above, we can easily see that Butler's preventive medicine campaign closely followed that model, beginning with step one. Butler's concerns regarding the future impact of yellow fever on his command drove him to prepare his Soldiers, his command, and the city of New Orleans for an epidemic. First and foremost, Butler did an excellent job of assessing the situation and devising a strategy. He relied upon and was greatly assisted by local expertise, which formed the foundation of his plan to suppress the outbreak of yellow fever in 1862. Next he implemented his 2-pronged preventive medicine strategy designed to detect the sources for the disease-incoming ships and unsanitary conditions. Butler's strategy of containment kept infected ships out of New Orleans via his quarantine stations, while his sanitation teams rid the city of the conditions that perpetuated the disease, effectively containing the conditions that supported its spread. These proactive actions allowed Butler to manage the population at risk, and to keep New Orleans free of a yellow fever epidemic in 1862. Butler's actions negated the need to apply the other steps in the Poles' model because the proactive actions of his command effectively stopped the disease through 1865. Butler's actions maintained the health of the command and the city in general while, perhaps more importantly, eradicating the paralyzing fear of yellow fever that gripped the Union Soldiers and the residents of New Orleans. As a commander, he kept his forces healthy and preserved combat strength for other operational requirements.

MG Butler's success in New Orleans in 1862 provided the Union Army with an effective model and means for dealing with the ravages of yellow fever in southern climates. The details of Butler's actions in New Orleans were well known in the northern press and broadcast throughout the Union. However, Civil War Army planners and commanders alike failed to recognize the utility of the preventive medicine successes that Butler's command had achieved in New Orleans and failed to standardize any proven preventive medicine tactics, techniques, and procedures across the Union Army. The 1864 debacle in New Bern provides proof and illustrates the consequences of this failure.

Because the Department of North Carolina failed to prepare for a yellow fever epidemic and were slow to detect, diagnosis, or acknowledge the outbreak, the Union command found itself thrust rapidly into the throes of a growing epidemic and was forced to execute all the steps of the Poles model at an expedited, feverish rate. The debacle of New Bern in 1864 probably could have been avoided; well over 1,000 lives, both military and civilian, saved; and combat power sustained had Union military commanders recognized, acknowledged, and publicized the lessons MG Butler had learned and applied in New Orleans only 2 years earlier. Unfortunately, the US Army of the 1860s had yet to develop the self-critical after action review and lessons learned culture that is institutionalized today.

When examining preventive medicine requirements and best practices, today's commanders have the benefit of a codified and time-tested preventive medicine biological strategy as presented in Army Regulation 40-5. (1) The regulation gives straightforward, clear guidance for any commander in regard to his or her role in protecting the health and safety of the Soldiers and civilians residing on the installation:
   Installation commanders are responsible for resourcing
   and implementing the preventive medicine components
   of installation infrastructure and services in coordination
   with the director of health services and the chief of
   preventive medicine services. Installation commanders
   provide the safe and healthy living and work environments
   and services such as drinking water, food, safe
   worksites, and recreational activities. Preventive medicine
   personnel provide the medical oversight and monitoring
   of installation infrastructure and services that may
   pose health threats. They provide the technical advice
   and assistance to installation commanders to minimize
   risks from such threats. (1) (p17)


Commanders today have the benefit of both historical hindsight and fully developed, time-tested biological contingency management models, as well as the expertise of preventive medicine professionals at the installation. However, commanders at all levels must still exercise their responsibility to fully and regularly engage and empower those preventive medicine personnel in order to be fully prepared for any biological contingency.

REFERENCES

(1.) Army Regulation 40-5: Preventive Medicine. Washington, DC: US Dept of the Army; 2007.

(2.) Davis B. The Civil War, Strange & Fascinating Facts. New York, NY: Fairfax Press; 1960:215.

(3.) Bell AM. Mosquito Soldiers; Malaria, Yellow Fever and the Course of the American Civil War. Baton Rouge, LA: Louisiana State University Press; 2010.

(4.) Bryant D. Quarantine flag. Maritime Professional wWebsite. January 2012. Available at: http://www. maritimeprofessional.com/Blogs/Maritime-Mus ings/January-2012/Quarantine-flag.aspx. Accessed December 6, 2012.

(5.) Frierson JG. The yellow fever vaccine: a history. Yale J Biol Med. 2010; 83(2):77-85. Available at: http:// www.ncbi.nlm.nih.gov/pmc/articles/PMC289 2770/. Accessed December 7, 2012.

(6.) Hall A. Spoons butler, yellow jack and the crescent city. 2010. Available at: http://deadconfederates. com/?s=yellow+jack. Accessed December 5, 2012.

(7.) Muniz ML. The yellow fever epidemic of 1864. The Palace. 2011; 10(6):15-16. Available at: http:// www.tryonpalace.org/pdfs/palace_magazine_ summer_2011.pdf. Accessed December 5, 2012.

(8.) Poles L. Principles of contingency planning for an unusual biological event. In: Sherner J, Shoenfeld Y, eds. Terror and Medicine: Medical Aspects of Biological, Chemical, and Radiological Terrorism. Lengerich, Germany: Pabst Science Publishers. 2003. Available at: http://www.pabst-science-publishers. com/index.php?33&backPID=33&begin_at=43&tt_ products=27. Accessed February 23, 2013.

COL Barry F. Graham, USA

COL Graham is an Academic Year 2013 Fellow at the US Army War College, Carlisle Barracks Pennsylvania.
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Author:Graham, Barry F.
Publication:U.S. Army Medical Department Journal
Geographic Code:1USA
Date:Apr 1, 2013
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